Week 9: NURS 171: Health Promotion and Part 2 Fluid, Electrolyte, Acid-Base Balance Flashcards
Health Promotion: Levels of Prevention
- primary
- secondary
- tertiary
Health Promotion: Levels of Prevention: Primary
Prevent/ slow onset of disease (no illness) -eating healthy foods -exercising -sunscreen -seat belt -immunizations ex: begin with weight bearing exercises as ages
Health Promotion: Levels of Prevention: Secondary
Detect and treat illnesses in early stages -screening activities and education for detecting illness in early stages: >breast self exam >testicular exam >physical examinations >BP and diabetes screening >TB test ex: colonoscopy
Health Promotion: Levels of Prevention: Tertiary
Stopping disease progression; return to pre-illness state
- stopping the disease from progressing
- returning the individual to pre-illness phase
- rehabilitation is main intervention
ex: total hip replacement
Hypovolemia
deficient fluid volume; not enough fluid
-fluid volume (and electrolytes) deficient from ECF
Causes for Hypovolemia
- surgery
- trauma
- dehydration
- fluid loss (bleeding)
- fluid shifts (ascites, into pleural space around lungs)
Signs + Symptoms of Hypovolemia
-Dehydration >thirst >increased heart rate >blood vessels constrict to maintain BP >temperature rises due to inability to cool self through perspiration >orthostatic hypotension
Alterations in Lab Values in Hypovolemia
- Increased BUN
- Increased Creatinine Ratio
- Increased Urine Specific Gravity
- Elevated Hematocrit
- Less water related to solid substances (less water than solutes)
Risk for Hypovolemia
- older adults (less muscle, water stored there, less stores)
- infants
- children
- patients with fluid loss
Hypervolemia
excessive retention of sodium + water in ECF
too much fluid
Causes of Hypervolemia
- over-hydration (IV, Oral)
- excess salt intake (retain fluid)
- kidney or liver disease
- poor pumping action of the heart
Signs + Symptoms of Hypervolemia
- Increased BP, bounding pulse
- Pale, cool skin
- Edema/ Ascites
- Increased respirations + shallow
- Crackles
- Rapid weight gain
Alterations in Lab Values for Hypervolemia
- Decreased BUN
- Decreased Hematocrit
- Decreased Urine Specific Gravity
Preventing Hypervolemia
- monitor intake and output
- monitor intravenous and place on electronic pump
White Blood Cells (WBC)
(5- 10 x 10^3 mm^3)
primary cell fighting infection and tissue damage
-measured in lab study CBC
Platelets
(150,000- 400,000 mm^3)
help the clotting process by sticking to the lining of blood vessels
-measured in the lab study CBC
Laboratory Studies Used to Evaluate Fluid + Electrolyte + Acid-Base Balance
- Complete Blood Count (CBC)
- Serum Electrolytes
- Serum Osmolality
- Urine Osmolality
- Urinalysis
Lab Study: Complete Blood Count (CBC)
- fluid status is reflected
- measures RBC, Hgb (hemoglobin), HCT (hematocrit), WBC, Platelets
Hemoglobin
the iron-containing pigment of red blood cells that carries oxygen from the lungs to the tissues
-measured in the lab study CBC
(Males: 14- 18 g/dL)
(Females: 12-16 g/dL)
Hematocrit (HCT)
a measure of the % of the red blood cells in whole blood
-as fluid level decreases, % of cells in ratio to blood increases
-as fluid levels increase, % of cells falls
-measured in the lab study CBC
(Males: 42- 52%)
(Females: 37- 47%)
Lab Study: Serum Electrolytes
sodium, potassium, chloride and bicarbonate (electrolytes)
Lab Study: BUN, Creatinine
sensitive measures of fluid status + kidney function
(BUN: 10- 31mg/dL)
(Creatinine: Male 0.6- 1.2 mg/dL, Female: 0.5- 1.1 mg/dL)
Lab Studies: Glucose
a simple sugar that is the end product of carbohydrate metabolism
(70- 110 mg/dL)
Lab Study: Serum Osmolality
measures solute concentration of blood
- increased means fluid volume deficit
- decreased means fluid volume excess
Lab Studies: Urine Osmolality
measures solute concentration of urine
- increased = fluid volume deficit
- decreased = fluid volume excess
Lab Study: Urinalysis
measures pH + specific gravity
-pH reflects acidosis + alkalosis
-specific gravity reflects fluid status
(increased specific gravity = fluid levels are low)
(decreased specific gravity = fluid is plentiful)
Facilitating Fluid Intake
- establish desired intake
- develop fluid schedule
- fluids may be given by mouth, via a tube, or intravenous
- replacement via NG or feeding tube if GI Tract intact
- parenteral intake may be needed
- set goal for the day (ie. 2500 mL over 24 hours)
Facilitating Fluid Restriction
- for a variety of reasons (impaired cardiovascular, liver, or renal function)
- determine amount of fluid allowed per shift
- usually includes all forms of intake (PO and IV)
- inform patients + caregivers of amount allotted
- offer ice chips + frequent oral hygiene for comfort
- keep liquids away from bedside
Intravenous Solutions
-Isotonic
-Hypotonic
-Hypertonic
(classified according to how they compare to the osmolality of blood serum (275-290 mOsm/Kg))
Isotonic Fluids
(250-375 mOsm/Kg)
-remain in the blood vessels
Ex:
0.9% NaCl= normal saline, lactated ringers
Hypotonic Solution
(< 250 mOsm/Kg)
-pull water out of blood vessels into cells
Ex:
D5W and 0.45 NaCl = half normal saline
Hypertonic Soluton
pulls water into the blood vessels -volume expanders (if i am putting more solutes, the water is going to come to the blood vessels) Ex: -D5 0.9% NaCl -D5 0.45% Nacl -D5RL
8 Blood Types
4 Groups: A, B, AB, O -A (+ or -) -B (+or -) -AB (+ or -) -O (+ or -) >inherit from parents >must receive only blood that is compatible with own blood group -Rh factor determines if you are (+) or (-); present (+), not present (-)
Cross-matching
- once blood passed initial screen test
- occurs between donated blood + potential donors blood
- identifies minor antigens that will affect the compatibility of the donor blood in the recipient
- RBC from donor are mixed with plasma from recipient
- if testing shows the risk of transfusion is low = safe to transfuse
People with Rh (+) may receive
Rh (+) or Rh (-) blood
People with Rh (-) may only receive
Rh (-) blood
Blood type O (-) is considered
a universal donor
Blood Type AB (+) is considered
a universal recipient
Blood Typing + Cross-matching Screen Tests
Hep B, Hep C, HIV, West Nile, Syphillis
Blood Products
- Whole Blood
- Red Blood Cells (RBC)
- Plasma
- Platelets
- White Blood Cells (WBC)
Blood Products: Whole Blood
contains RBC, WBC and platelets suspended in plasma
Blood Products: Red Blood Cells
-removed from whole blood for transfusion
-RBC that are transfused (packages RBCs or PRBCs) can raise clients hematocrit (HCT) + hemoglobin (Hgb) level while minimizing an increase i volume
(most common transfusion)
Blood Products: Plasma
- liquid portion of blood
- makes up 55% of blood volume
- includes albumin, clotting factors, immune globulins (may be transfused as a whole or be separated)
Blood Products: Platelets
help the clotting process by sticking to the lining of blood vessels
(150,000- 400,000)
Blood Products: White Blood Cells
for clients with infections not responsive to antibiotic therapy
(5- 10 x 10^3 mm^3)
Initiating a Transfusion
-verify written prescription for the blood
-identify patient
-obtain vital signs prior to initiating
>if temp elevated, notify healthcare provider
-inspect intravenous site for patency + size
-identify blood product
-inspect IV site
Transfusion Reaction
- ensure to follow all safety checks + protocols
- start transfusion slow
- remain with patient for first 5 minutes
- assess again at 15 minutes
Examples of Transfusion Reactions
- allergic
- bacterial
- febrile
- hemolytic
- circulatory overload
Transfusion Reaction: Allergic
allergy to blood being transfused -Signs + Symptoms: >flushing >itching >wheezing >urticaria (hives) >anaphylaxis
Transfusion Reaction: Allergic Nursing Responsibilities
- stop transfusion
- replace with saline solution
- notify physician immediately
- administer prescribed antihistamine
Transfusion Reaction: Bacterial
contamination of blood -Signs + Symptoms: >fever >chills >vomiting >diarrhea >hypertension
Transfusion Reaction: Bacterial Nursing Responsibilities
- stop transfusion
- replace with saline solution
- notify physician immediately
- administer prescribed antibiotics
- treat symptoms
Transfusion Reaction: Febrile
temperature elevation due to sensitivity to WBCs, plasma protein or platelets -Signs + Symptoms: >fever >chills >warm, flushed skin >aches
Transfusion Reaction Febrile Nursing Responsibilities
- stop transfusion
- replace with saline solution
- notify physician immediately
- treat symptoms
Transfusion Reactions: Hemolytic
destruction of RBCs as a result of infusing incompatible blood -Signs + Symptoms: >fever >chills >dyspnea >chest pain >tachycardia >hypotension >can be fatal
Transfusion Reactions Hemolytic Nursing Responsibilities
- stop transfusion
- replace with saline solution
- notify physician immediately
- send blood including tubing and filters along with sample of venous blood and first voided urine to lab for analysis
- treat shock
Transfusion Reaction: Circulatory Overload
administering too great volume or too rapidly -Signs + Symptoms: >persistent cough >crackles (lung sound) >hypertension >distended neck veins
Transfusion Reaction Circulatory Overload Nursing Responsibilities
- slow or stop transfusion
- monitor vital signs
- place client upright
- notify physician
Guidelines for Measuring Intake
- identify factors that can affect fluid intake
- measure intake: oral (liquids or those that melt at room temp), intravenous fluids, enteral or parenteral nutrition fluids
- record info per policy
- document in mL
Guidelines for Measuring Output
- urine output
- empty wound drains or other devices + measure volume
- record per policy
- be aware of insensible losses that can not be measured (wound dressing, perspiration)
